The costs of schizophrenia

Schizophrenia is regarded as the most expensive mental illness because of its specific symptoms and characteristics (e.g. early onset, often chronic course, high rates of readmission to hospital treatment, high rate of disabilities and extensive rehabilitative interventions), which prove to be extremely costly. Despite this, studies on the financial aspects of schizophrenia or the provision of care for schizophrenic patients has become an issue of psychiatric research only since the beginning of the reform of mental healthcare. Early cost studies had been conducted in the United States (US) during the fifties. Since then, they have grown in number not only in the US and in Great Britain, but also on the Continent of Europe. On an international level, comprehensive literature concerning methodology has attempted to establish cost studies as an integral part of mental health services research. Germany, however, is far behind international developments. Although the fundamental lack of empirical data on costs both in psychiatry as a whole and in schizophrenia had already been ascertained in a large national survey called "Psychiatrie-Enquête" in the mid-seventies, little has changed since then. One reason for these possibly great methodological problems is associated with the assessment of cost data in fragmented community mental health care networks, which in Germany include the additional obstacle--unlike abroad--of non-availability of access to data from case registers. Psychiatric case registers are not permitted in Germany because of very strict data protection laws. Despite the problems in methodology, there is an urgent need in Germany to remedy the lack of cost data for schizophrenic-patient care. The pressure of curbing costs in health care will probably force the German mental health care services to provide detailed cost data with regular reports in the future.     

Occultism, parapsychology and the esoteric from the perspective of psychopathology]

The concepts and main themes of occultism, parapsychology and esoterics are set in comparison to religion, spirituality, mysticism. The cultural relativity of these concepts is emphasised. Occultism means dealing with phenomena, processes, and/or powers which are not accessible to "normal perception". The manipulation of such powers is effected via (white, black, grey) magic. Parapsychology, in its popular sense, deals with occult phenomena, whereas scientific parapsychology investigates them empirically. Esoterics is a complex of beliefs within a hermetic tradition about occult processes and about desting after death. Transpersonal psychology deals with these issues while calling them "spiritual". Effects of paranormal experiences and actions on the side of the actor as well as the adept are discussed: personality types, interpersonal effects, crises and psychoses (mediumistic psychoses). The concept of dissociation of subpersonalities (subselves) appears to be a viable perspective to explain these phenomena. In mediumistic psychoses, the splitting of non-ego parts of the psyche leads to a manifestation of schizophrenic symptoms. Dangers for mental health are an ego inflation by self-attribution of "superhuman" power. A personality disposition for parapsychological perception and/or action may be seen in schizotypia and similar near-psychotic "personalities up the border". Adepts of occultism may present with a "false self" in the sense of Winnicott.     

Habitual dependence on modern imaging modalities: the new golem

Modern imaging techniques have been taking over our medical life, but none denies the progress that has followed introduction of modern imaging modalities. For the generation of younger physicians who entered the profession after the introduction of these techniques, use of US, CT, MRI and the like is natural and often applied. But the patient is not computerized and medicine is far from being a pure science. 3 cases of common surgical problems are presented in which excessive use of diagnostic modalities resulted in unnecessary operations, thus leading to unnecessary morbidity. In these days of soaring medical expenses, many unnecessary imaging and laboratory studies are done for reasons of "defensive" medicine. It is important to fortify the position of clinical diagnosis, but making clinical decisions without requiring expensive and sometimes misleading imaging studies significantly reduces costs. Admittedly, courage and firm professional backbone are required to face a lawyer or a judge and say: "This CT or US study would not have changed my clinical decision; it would have made no positive contribution to it, and might even have mislead me." This paper comes to remind physicians of the importance of clinical diagnosis and the need to develop and rely on primary medical skills. Machines and laboratory tests are aids to diagnosis, they do not make the diagnosis.     

The risk for psychiatric disorders in relatives of schizophrenic and control probands: a comparison of three independent studies

BACKGROUND: Although replication is the heart of science, psychiatric geneticists rarely have the opportunity to replicate findings, especially more than once. METHODS: This article reviews results from three independent family studies of schizophrenia on which one of us conducted diagnostic reviews: the Danish Adoption Study (DAS), the Iowa 500 non-500 family study (IFS), and the Roscommon Family Study (RFS). We utilized DSM-III or DSM-III-R criteria and meta-analysis techniques. RESULTS: The odds ratios (OR) in personally interviewed, first degree biological relatives of schizophrenic and matched control probands for schizophrenia, other non-affective psychoses (ONAP), schizotypal personality disorder (SPD), unipolar affective illness (UPAI), bipolar affective illness (BPAI), and anxiety disorders were homogeneous across studies. For alcoholism, ORs were significantly heterogeneous. Schizophrenia, SPD and ONAP strongly aggregated in relatives of schizophrenic probands with decreasing common OR estimates of 16.2, 5.0 and 4.0, respectively. The common OR for anxiety disorders was 1.1, indicating no familial co-aggregation. For UPAI and BPAI, the common ORs exceeded unity (1.3 and 1.9, respectively), although only the former was statistically significant. CONCLUSIONS: Schizophrenia strongly aggregates in families and shares familial factors with SPD and ONAP but not anxiety disorders. The familial factors of aetiological importance for schizophrenia and affective illness may be weakly related. With the exception of alcoholism, the patterns of psychiatric disorders in relatives of schizophrenic and control probands in these three studies were sufficiently similar that, despite their methodological differences, they can probably be viewed as replications of one another.     

Theory and philosophy in social psychology.

Social psychologists are generally very empirical, and their research is usually theoretically oriented. However, what passes for theory is often no more than a couple of vague statements. Nevertheless, coming from the tradition of Kurt Lewin, we tend to reject papers that do not test a "theory". On the other hand, we pay no attention to theories lacking experimental support. Clinical observations are not enough. There is very little concern with philosophical issues. Ken Gergen of Swarthmore College is a notable exception and is often on convention programs. His comments about "historicism" in social psychology have caused some published rebuttals, but our members are largely not very concerned with this or with Gergen's more recent forays in "social re-constructionism". (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of stressful life events and schizophrenic relapse.

In this prospective, longitudinal study, 11 recent-onset schizophrenic outpatients who met criteria for psychotic relapse or significant psychotic exacerbation during a 1-year period of standardized maintenance medication, and 19 patients who did not relapse during this follow-up period, were interviewed monthly regarding life events. As hypothesized, for relapsing patients, a significantly higher number of independent life events (those not the result of symptomatology or personal influence) occurred in the month preceding relapse. This increase was apparent relative to either the analogous month of a "nonrelapse" period in the same patient or the average number of independent events per month during a 1-year standardized medication period for nonrelapsing patients. The methodological advances of this design as well as the consistency of these findings with those of previous retrospective studies supports the hypothesis that life events may sometimes "trigger" schizophrenic episodes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypofrontality revisited: a high resolution single photon emission computed tomography study in schizophrenia

Hypofrontality or reduced activity in the prefrontal cortex, measured as reduced frontal perfusion or glucose uptake, has gained the status of an established finding in the medical literature on schizophrenia. Many relevant studies, however, have potential sources of bias, such as small subject numbers, or unreliable performance of activation tasks by the patients during the scanning procedure. Seventy patients with non-affective and non-organic psychoses were recruited--most qualifying for DSM III-R schizophrenia or schizophreniform psychosis (n = 60)--together with 20 healthy volunteers. They underwent single photon emission computed tomography with 99mTc-exametazime, carried out at rest. Tracer uptake was normalised to the occipital cortex. Group differences in tracer uptake were predicted in anterior regions of interest (prefrontal cortex and mesial frontal/cingulate cortex). Actively psychotic (including schizophrenic) patients not taking any drugs showed increased uptake in the prefrontal cortex. Reduced tracer uptake occurred in the mesial frontal cortex of schizophrenic patients, particularly if they were taking drugs. Relatively increased prefrontal tracer uptake associated with relatively decreased mesial frontal uptake characterised the patients in comparison with the controls. Generalised hypofrontality is, therefore, not a feature of schizophrenic patients at rest whether taking drugs or not.     

Q-wave versus non-Q wave myocardial infarction: a meaningless distinction

The whole subject can thus be summed up in two statements. 1. Every appropriately designed study comparing first Q and NQMI's has found no difference in post-MI course of the two categories and no foundation for the common notion that the NQMI is a uniquely "unstable" entity, to be classed with unstable angina in terms of prognosis and management. Nine such studies have been published. On the other hand, all studies alleging the "unstable" character of the NQMI have been invalidated by major flaws, chief among them the comparison of undifferentiated mixtures of first and subsequent infarcts with widely differing mortality and morbidity. This confusion is further compounded by the fact that subsequent infarcts generate Qwaves less than half as often as first infarcts. 2. All current studies indicate that there is no benefit to an invasive as compared with a conservative protocol for management of NQMI. Since the characterization of an infarct as "non-Q' conveys no therapeutic implications, the classification becomes irrelevant and should be discarded. Two quotations sum the whole matter succinctly. Moss (63) commented that "The Q-wave versus non-Q-wave categorization does not provide sufficient sensitivity, specificity, or predictive accuracy about the subsequent clinical course of patients with a first myocardial infarction to use it as reliable data in the clinical decision-making process." Surawicz (64) put the matter even more concisely: ". . . a non-Qwave MI is not a unique entity: rather it is a smaller and less extensive MI." In a word, the magnitude of a myocardial infarction should be judged on anatomical and functional considerations rather than on the designation of Qwave versus non-Qwave infarction.     

The perceived quality of hospital care

For the functional psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services; and surveys of elderly persons sampled from the general population. A conspectus of published data from both sources leads to the following conclusions: States phenomenologically similar to those found in clinics do occur in the community in non-trivial numbers. There is no notable divergence in the information obtained from clinical series and from population-based surveys. These states are more common in women, they become more common with increasing age and are sometimes associated with decline in cognitive performance or with degenerative changes in the brain revealed by neuroimaging. Genetic factors appear to be less important than in early-onset psychoses but remain ill-defined, and the roles of social isolation and disorders of personality have not yet been sufficiently elucidated. Both clinical and community-based studies have found an association with sensory impairment. The community-based data suggest that paranoid symptoms may be detectable at subclinical level, and an association between them and cognitive impairment is demonstrable in individuals who are not diagnosable cases either of psychosis or of dementia. Differences exist between late-onset paranoid psychoses and affective psychoses in symptomatology and response to treatment. These observations confirm the importance of the late-onset psychoses for research directed towards uncovering the origins of psychotic symptoms in any age group.     

The marathon encounter group: A review of the outcome literature.

45 investigations of the marathon encounter group are systematically evaluated. Comparisons are made within sections on time format, Ss, leaders, treatment, testing periods, and outcome criteria. All but 6 studies used "normal" college volunteers as Ss. Some positive results were found in varied aspects of personal or social functioning, although the group effects seemed to be temporary. The methodological shortcomings are considerable. The superiority of the marathon encounter group over traditional spaced group treatment is not established, and the treatment methods most effective in the extended session still need to be identified. Critical limitations of the studies indicate that further investigations of variables predictive of desired outcomes should use treatment control groups, defined treatment formats, multiple outcome criteria, and comprehensive follow-up investigations. (3 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Forgetting rates in neuropsychiatric disorders

OBJECTIVE: Previous studies have attributed accelerated forgetting rates on recognition memory tasks to temporal lobe pathology, but findings in some patient groups may have been attributable to metabolic disruption. Findings in psychiatric disorders such as schizophrenia are conflicting. The purpose of the present study was to compare forgetting rates in patients with confusional states (post-electroconvulsive therapy (post-ECT), delirium), with those obtained in schizophrenic patients (with putative temporal lobe pathology), non-ECT depressed patients, and healthy controls. The findings could also be compared with previous reports in patients with head injury, focal structural lesions, and Alzheimer's dementia. METHODS: Two studies employed a picture recognition task to examine forgetting rates, the first between delays of 1 minute, 15 minutes, and 30 minutes, and the second between delays of 10 minutes, 2 hours, and 24 hours. RESULTS: There were no significant differences in forgetting rates between 1 minute and 30 minutes, but the ECT group showed accelerated forgetting between 10 minutes and 2 hours compared with healthy controls, associated with a rapid decline in "hit rate". This was not attributable to differential changes in either depression or severity of memory impairment. There were no differences in forgetting rates across the other subject groups. CONCLUSION: Post-ECT confusional state patients (similarly to "within post-traumatic amnesia" patients with head injury) show accelerated forgetting on a recognition memory task and, in this, they contrast with patients who have focal structural lesions or widespread cortical atrophy. Accelerated forgetting may reflect the effect of disrupted cerebral metabolism on either "consolidation" or memory "binding" processes.     

Drug abuse and suicidal tendencies

Among the psychotic symptoms in juvenile drug-consumers one can find autonomous, i.e. drug-independent developments, whose connection with the drug-abuse is to be assessed in differing ways. A beginning psychosis can be modified in its actual symptoms by drug-consumption. On the other hand one must consider the manifestation of a latent psychosis or purely symptomatic psychosis, which, in its symptoms, can hardly be distinguished from schizophrenia. Finally drug-induced personality-changes can develop together with secondary psychotic symptoms. Psychotic symptoms are determined and influenced in a varying degree by drugs. Both after short drug-consumption and after a longer drug-anamnesis with polytoxicomanic symptoms psychotic syndromes can be discovered. Even the initial psychotic symptoms can hint at an adverse development and a bad prognosis. Sometimes the drug-experiences conceal the autonomous development of the psychosis, which, as a rule, shows predominantly schizophrenic symptoms. In addition to a quick change of the actual symptoms, acute states of confusion and depressive-suicidal syndromes, flash-back and horror-trip phenomena, closely connected with the psychotic experience, and a schizophrenic colouring of affective psychoses can be found as frequently drug-induced modifications of the psychotic symptoms. Furthermore one finds an increase of symptoms and of the psychotic episodes in the case of psychoses of the schizophrenic variety which have already begun. Grave personality changes with psychotic symptoms after chronic drug-abuse can cause differential-diagnostic difficulties.     

Umbrella hypotheses and parsimony in human evolution: a critique of the Aquatic Ape Hypothesis

Conventionally, anthropologists have sought to explain a multitude of unique features of modern humans as the outcome of a single adaptive breakthrough. These "umbrella hypotheses" are aesthetically appealing because they appear to be parsimonious. As internally consistent hypotheses about the past, they are very difficult to prove incorrect in an absolute sense. Anthropology has often rejected them by consensus without developing explicit reasons. This essay explores one example of these models, the Aquatic Ape Hypothesis, the proponents of which continue to argue that they have not received a fair hearing among anthropologists. The hypothesis is troubled by inconsistencies and has not been reconciled with the fossil record. More importantly, its claim to parsimony is false. The numerous "explanations" for individual anatomical traits that it generates constitute premises that are not better founded than competing terrestrial "explanations". The unifying theme of aquatic adaptation is considerably less parsimonious than the assumption that our lineage has always been terrestrial. Finally, the mosaic pattern of hominid evolution demonstrated by the fossil record will not support this or any single cause theory. Most of these criticisms have been previously voiced in one form or another, yet umbrella hypotheses ranging from mainstream science to the paranormal maintain their popularity among students, general audiences, and scholars in neighboring disciplines. One reason for this is that simple answers, however wrong, are easier to communicate and are more readily accepted than the more sound but more complex solutions. Evolutionary science must wrestle with this problem both in its own community and in the education of the public.     

Can after-the-fact designs test functional hypotheses, and are they needed in psychology?

While various methodological psychologists have traditionally claimed that ex-post facto or after-the-fact investigational designs cannot test functional hypotheses of "causal" type, it is maintained in the present paper that they can under certain circumstances. To the usual objection that the "treated" groups in after-the-fact studies have not been equated by randomization or matching to the "control" groups, it is argued that where suitable data are available, judicious matching can be done and conceivable regression effects avoided or discounted. While admittedly probable functional determinants ("causes") are preferably investigated by classical experimental designs, there are important fields, such as the study of the effects of physical disorders and investigations of the actual determinants in real-life situations, in which an appropriate series of after-the-fact analyses is essential for the testing of the alleged causal connections. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of obstetric epidural analgesia. II. Caesarean section

A questionnaire was sent to 260 women who in 1979 had undergone a caesarean section under either epidural or general anaesthesia. Those women who had an epidural for their caesarean section were on average very well informed about the procedure. In contrast, those who had been given a general anaesthetic felt that they had been badly or inadequately informed. Over 90% of the patients of both the epidural and the general anaesthetic groups described the type of anaesthesia which they had received as "very good" to "adequate". In the epidural group, 80% of the patients described the experience of the birth as very intense. Headache, back pain and other complaints such as abdominal pain and wound pain were significantly more frequent in the general anaesthetic as compared to the epidural group. 85.8% of the women given an epidural said that they would choose the same again for a future caesarean, 12.1% would not. Of the group given a general anaesthetic, 29.9% said that in the future they would choose an epidural, and 62.3% that they would prefer to have a general anaesthetic again. The Apgar score at one minute, and the umbilical artery pH values of the newborn of the epidural group were significantly better than those of the general anaesthetic group, whereas at 5 and 10 min the Apgar scores of the babies of both groups showed no differences.     

Therapist experience, general clinical ability, and treatment outcome in schizophrenia.

Knowledge of the effect of therapist training and experience on the outcome of treatment of schizophrenic patients is scanty. The present article presents data systematically collected in the course of a controlled comparison of the effects of 5 different treatment methods in schizophrenia (individual psychotherapy, ataractic drug treatment, individual psychotherapy and drug treatment, ECT, and "milieu" care) involving 228 1st-admission schizophrenics without significant prior treatment and 38 psychiatric residents or recently graduated psychiatrists. Among the 23 outcome variables studied (including the Menninger Health-Sickness Scale, the Camarillo Dynamic Assessment Scale, the MMPI, the Communication subscale of the MACC Behavioral Adjustment Scale, and the Clyde Mood Scale), there was not a single instance in which the effect of therapist experience and general clinical ability was significantly related to outcome. There appeared to be, however, differences among therapists' results that were not related to experience and general clinical ability, particularly in relation to the length of time that they kept their patients in hospital. Drug treatment tended to override but perhaps not entirely eliminate these effects. (36 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The status of alexithymia as a risk factor in medically unexplained physical symptoms

Some decennia ago, the concept of alexithymia was developed from the clinical experience of psychosomaticians who at the time were largely working within a psychoanalytic frame of reference. Alexithymia can briefly be described as a cognitive-affective disturbance characterized by difficulties in differentiating one's feelings and expressing them in words. Clinicians who treat patients with medically unexplained physical symptoms may often recognize alexithymic features in their patients. It is supposed that alexithymia could be a predisposing factor for the development or persistence of medically unexplained physical symptoms. In this review, the concept of alexithymia as well as paradigmatic shifts in psychoanalysis and psychosomatics are discussed to place the concept of alexithymia in its epistemiological context. Furthermore, the empirical literature on the association between alexithymia and medically unexplained physical symptoms is reviewed. The main conclusions are that alexithymia appears to be a theoretically important and clinically appealing concept, but that so far the empirical evidence that alexithymia predisposes to the development or persistence of medically unexplained physical symptoms is imperfect. This is mainly because of the cross-sectional design of most studies and is due to other methodological shortcomings, such as the lack of allowance for depression and anxiety as possible confounding factors. Suggestions for future research are made.     

Some methodological issues in neuroradiological research in psychiatry

An outline is given of some of the methodological issues discussed in neuroradiological research on psychiatric illness. Strengths and shortcomings of magnetic resonance imaging (MRI) in depicting and quantifying brain structures are described. Temporal lobe anatomy and pathology are easily accessible to MRI, whereas limits on anatomical delineation hamper approaches to frontal lobe study. White matter hyperintense lesions are sensitively depicted by MRI, but specificity is limited. Distinction of vascular and primary degenerative dementia is considerably improved by CT and MRI analysis. Computed tomography (CT) and MRI have enhanced the understanding of treatable organic psychiatric disorders, e.g., normal pressure hydrocephalus. Subcortical and white matter pathology has been replicated in CT and MRI studies of late-onset psychiatric disorders, clinical overlap with cerebrovascular disease or neurodegeneration may be of import. Transcranial sonography findings of brainstem structural change specific to unipolar depression may contribute to the understanding of affective psychoses. Magnetic resonance spectroscopy and functional MRI are likely to stimulate psychiatric research in the future.